Provider Demographics
NPI:1902920168
Name:CANZANESE, VINCENT MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:MICHAEL
Last Name:CANZANESE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:572 S HEILBRON DR
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-4500
Mailing Address - Country:US
Mailing Address - Phone:610-891-6796
Mailing Address - Fax:610-690-2689
Practice Address - Street 1:334 BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-3631
Practice Address - Country:US
Practice Address - Phone:610-543-1765
Practice Address - Fax:610-690-2689
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARPO4O150L183500000X
DEA1-0003363183500000X
NJ28R102884300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist